How frequently is this preventive service being provided?

Overall
A nationally representative survey conducted from 2005-2010 found that adults were screened for tobacco use during 65.6% of all ambulatory care adult visits. Of those who were identified as tobacco users, roughly 20.7% received tobacco cessation counseling.8

Screening for tobacco use was lower among Hispanic patients than among non-Hispanic white patients.

Outpatient visits that were >20 minutes were more likely to include tobacco counseling compared to shorter visits.9

Pregnancy
A study conducted in New Jersey found that 92.7% of women who smoked before pregnancy were asked about tobacco use by their prenatal care provider and that 56.7% of women who were smoking when they entered prenatal care received smoking cessation counseling.10

According to a nationally representative study, fewer physicians are currently doing all five major smoking intervention steps for pregnant patients (the 5-As), compared to a sample from 1988.11

What are the best screening practices identified in the literature?

The USPSTF identifies the 5-As behavioral counseling framework as a good strategy to begin conversations with patients about smoking cessation.12 Also recommended by The American College of Obstetricians and Gynecologists (ACOG), the 5-As include:

Ask about tobacco use.

Advise to quit using clear, personalized messages.

Assess willingness to make a quit attempt.

Assist in quit attempt.

Arrange follow-up and support.

When the 5-As is integrated into existing routines, the time commitment is usually 7 to 10 minutes.13

What are the best interventions identified in the literature?

A meta-analysis, focused on the general population of smokers, found that teams of physicians and non-physicians using multiple intervention modalities on multiple occasions produce the best results. Providers can improve intervention success by increasing the number of contacts, types of contacts, and number of people making contacts. The duration of contact is the strongest predictor of quitting.

A second meta-analysis found that self-help strategies alone are ineffective and reinforced the effectiveness and importance of clinicians treating tobacco use/dependence with a combination of counseling and (unless contraindicated) pharmacotherapies. It also highlighted that nicotine gum is an important aid for cessation (on average more than doubling odds of cessation).14

Although combination therapy (i.e. counseling and medication) has been found to be most effective in general populations, the USPSTF found inadequate evidence to evaluate the use of pharmacotherapy in pregnant women.15 However, If women are unable to quit on their own or with counseling, ACOG recommends that nicotine replacement therapies be considered under the close supervision of a provider.16

What are some ideas to address these barriers?

Some women may be heavily addicted to nicotine and continue to smoke during pregnancy. Therefore providers should repeat and continue efforts to achieve tobacco cessation, as well as screening for other substance use, throughout the pregnancy.19

Develop office routines and practice patterns that could improve management of patients that smoke or use tobacco.

What does the Affordable Care Act cover?

All Marketplace plans and many other plans must cover tobacco use screening for all adults and cessation interventions for tobacco users without charging a copayment or coinsurance. This is true even if the patient has not met their yearly deductible. This applies only when these services are delivered by a network provider.20

The Departments (Departments of Labor (DOL), Health and Human Services (HHS), and the Treasury) will consider a group health plan or health insurance issuer to be in compliance with the requirement to cover tobacco use counseling and interventions, if, for example, the plan or issuer covers without cost-sharing:21

Screening for tobacco use; and,

For those who use tobacco products, at least two tobacco cessation attempts per year. For this purpose, covering a cessation attempt includes coverage for:

Four tobacco cessation counseling sessions of at least 10 minutes each (including telephone counseling, group counseling and individual counseling) without prior authorization; and

All Food and Drug Administration (FDA)-approved tobacco cessation medications (including both prescription and over-the-counter medications) for a 90-day treatment regimen when prescribed by a health care provider without prior authorization.

What does Medicaid cover?

Each state has its own plan for Medicaid coverage. To find out more about Medicaid and CHIP eligibility and coverage in your state, please visit Medicaid.gov.

NOTE: Section 4107 of the ACA, P.L. 111-148, amended Title XIX (Medicaid) of the Social Security Act to provide for Medicaid coverage of comprehensive tobacco cessation services for pregnant women, including both counseling and pharmacotherapy, without cost sharing. This is only one of a number of important ACA provisions that impact tobacco cessation coverage for tobacco users in general, including pregnant tobacco users.22

Treating Tobacco Use and Dependence: 2008 Update is a Public Health Service-sponsored Clinical Practice Guideline that contains strategies and recommendations designed to assist clinicians; tobacco dependence treatment specialists; and health care administrators, insurers, and purchasers in delivering and supporting effective treatments for tobacco use and dependence.

The Smoking Cessation and Reduction in Pregnancy Treatment (SCRIPT) Program from the Society for Public Health Education (SOPHE) is an evidence-based program shown to be effective in helping pregnant women quit smoking. SCRIPT is component of a patient education program for prenatal care providers based on the 5 A's and outlines a self-evaluation process to help build women's smoking cessation success over a seven-day period; written in the 5-6th grade reading level. SOPHE also offers Adopting SCRIPT in your Organization Training which trains health professionals to promote, implement, and evaluate SCRIPT.